Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to protect the residents' right to be free from verbal and
physical abuse by another resident. These failures affect four (R1, R2, R3, R4) residents out of four
residents reviewed for abuse in a sample list of seven residents.
Findings include:
The facility policy titled Abuse Prevention effective May 2021 documents the facility affirms the right of our
residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined
below. Abuse is the willful injection of injury, unreasonable confinement, intimidation, or punishment with
resulting physical harm, pain or mental anguish. Willful, as used in this definition of abuse, means the
individual must have acted deliberately, not that the individual must have intended to inflict harm or injury.
Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal
punishment. Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging
and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability
to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, or
saying things to frighten a resident such as telling a resident that he/she will never be able to see his//her
family again.
The Final Report to the State Agency dated 9/27/24 documents, (R1, R2) were sitting in the dining room at
their table. (R1) called (R3) a f****** r***** (expletives). (R2) told (R1) not to call people those names. (R1)
then called (R2) the same thing. (R2) told (R1) not to call him those names. (R1) called (R2) the same thing
again. (R2) then got up from the table and started swinging at (R1) three times. Residents were separated.
(R1) continued to say those names to (R2) as (R1) was getting removed from the dining room.
1.) R1's Undated Face Sheet documents medical diagnoses of Dementia with Psychotic Disturbances,
Cerebral Palsy, Major Depressive Disorder, Aortocoronary Bypass Graft and Seizures.
R1's Minimum Data Set (MDS) dated [DATE] documents R1 as moderately cognitively impaired. This same
MDS documents R1 as being independent in all assessed areas including transfers and mobility.
R1's Care plan intervention dated 10/30/2023 instructs staff to ensure a safe environment.
2.) R2's Undated Face Sheet documents medical diagnoses as Anxiety, Psychotic Disorder with Delusions,
Schizoaffective Disorder, Catatonic Schizophrenia, Bipolar Disorder, Nonpsychotic Mental
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 4
Event ID:
145370
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145370
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sullivan Healthcare & Senior Living
11 Hawthorne Lane
Sullivan, IL 61951
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600
Disorder and Delirium.
Level of Harm - Minimal harm
or potential for actual harm
R2's Minimum Data Set (MDS) dated [DATE] documents R2 as moderately cognitively impaired. This same
MDS documents R2 requires set up assistance with eating.
Residents Affected - Some
R2's Care plan intervention dated 3/10/2024 documents R2 is to be approached in a calm, non-threatening
manner. This same care plan documents an intervention dated 2/10/2023 which instructs staff to provide a
safe, calming environment.
3.) R3's Undated Face Sheet documents R3's medical diagnoses as Diabetes Mellitus Type II,
Gastroesophageal Reflux Disorder (GERD), Dementia, with Agitation, Moderate Intellectual Disabilities,
Depression, Convulsions and Intermittent Explosive Disorder.
R3's Minimum Data Set (MDS) dated [DATE] documents R3 as moderately cognitively impaired. This same
MDS documents R3 as requiring set up assistance for eating, supervision for toileting, and moderate
assistance for bathing, dressing, and personal hygiene.
R3's care plan intervention dated 3/13/24 instructs staff to follow the abuse policy toward other residents.
4.) R4's Minimum Data Set (MDS) dated [DATE] documents R4 as cognitively intact. This same MDS
documents R4 requires set up assistance with eating and moderate assistance with transfers.
R4's Care plan intervention dated 1/19/2023 instructs staff to maintain a calm environment.
On 10/10/24 at 12:50 PM R1 stated, I didn't like that way (R3) was looking at me so I called him names.
Then (R2) started yelling at me so I called him names too. It is not nice to yell. Then (R2) got up and hit me
in the face. That wasn't nice either. I tried to hit (R2) back but I think I missed. Then they (staff) made me
leave. I get to sit somewhere now where (R3) can't look at me and (R2) won't hit me. It is better now. I don't
like (R3). (R3) is not a nice person.
On 10/10/24 at 11:45 AM R2 stated R1 was yelling and cursing at R3. R2 stated R3 was sitting at another
table. R2 stated R1 and R3 had 'trouble' before and had to be separated. R2 stated (R1) was calling (R3) a
f****** r***** (expletives) loud enough for everyone to hear. That is not right. I told (R1) not to say things like
that. (R1) just kept yelling that at (R3). (R3) did not say anything back. So, I told (R1) to shut up because he
was being mean to (R3). Then (R1) started yelling at me and calling me a f****** r***** (expletives). I got so
tired of hearing (R1) being mean I got up and hit him. (R1) got what he deserved. I told (R1) 'Do you want
more of that because there is plenty more. I will f*** (expletive) you up like (famous boxer). Then they (staff)
walked (R1) out of the dining room so I sat down and finished eating.
On 10/10/2024 at 3:00 PM R4 stated, (R1, R2) were yelling so loud. (R2) was calling (R1) a f****** r*****
(expletives) and (R1) was saying the same thing back to (R2). I was sitting at the table in between both of
them (R1, R2). I just put my head down and didn't say anything. I put my head down too so I wouldn't get hit
because (R2) hit (R1). I was really scared. The staff came over and broke up the fight. I think (R1) started it
by yelling at (R3). There was just so much yelling and fighting. It was an awful day.
On 10/10/24 at 12:35 PM R5 stated, Those two (R1, R2) were yelling at each other that night
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145370
If continuation sheet
Page 2 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145370
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sullivan Healthcare & Senior Living
11 Hawthorne Lane
Sullivan, IL 61951
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600
Level of Harm - Minimal harm
or potential for actual harm
(9/24/24). I was surprised to see (R2) yell and hit (R1). (R2) is normally pretty quiet. (R1) got it that night
though. It is always loud in the dining room because there are a lot of people who yell out, but they don't
know what they are doing. You know (R1, R2) were screaming because you could hear them (R1, R2) over
everybody else. I think I learned some new words that night. Not good ones if you know what I mean. I
wasn't scared or anything, but it would be nice just to eat my dinner in peace.
Residents Affected - Some
On 10/10/24 at 1:15 PM R6 stated (R1) started yelling at (R3). (R3) was sitting at another table. (R2) yelled
at (R1) then (R2) got up from the table, walked over to (R1) and hit (R1). They (R1, R2) were calling each
other bad names. They (R1, R2) were calling each other f****** r****** (expletives). I don't sit with them (R1,
R2). I think (R4) was sitting there with them (R1, R2) too, but I don't think (R4) did or said anything. (R1)
was still yelling at (R2) when the staff were trying to walk him out (of the dining room). (R2) sat back down
but then he got up and tried to walk toward (R1) again but the staff got him settled down again.
On 10/10/24 at 12:00 PM V4 Licensed Practical Nurse (LPN) stated V4 did not see the initial part of the
interaction between R1 and R2. V4 stated, I was at my medication cart near the dining room and heard the
commotion. By the time I got into the dining room, I did see (R2) stand up and try to hit (R1). (R1, R2) were
yelling at each other. Staff intervened and removed (R1) from the dining room.
On 10/10/24 at 1:20 PM V8 Resident Care Coordinator (RCC)/Licensed Practical Nurse (LPN) stated V8
did not witness the beginning of the altercation between R1 and R2. V8 stated, I was on my way out of the
building, so I was walking by the dining room area. I heard (R1) say something to (R2) and then saw (R2)
get up and tried to hit (R1). I was too far away to see if (R2) actually made contact with (R1) but he could
have.
On 10/10/24 at 3:30 PM V10 Certified Nurse Aide (CNA) stated V9 and V10 CNA's were passing dinner
trays in the dining room on 9/24/24. V10 stated she heard (R2) yelling at (R1). V10 stated, By the time I got
over to their (R1, R2) table, (R2) was standing up and walked over to (R1) and started hitting (R1). I stood
in between (R1, R2) to prevent any more hitting. I was scared to do that, but I knew it was best for (R1, R2)
to not get hurt. I knew I needed to break up the fight. I walked (R1) out of the dining room after (V9) CNA
assisted (R2). (R1, R2) were yelling at each other as I was walking (R1) out of the dining area. This isn't the
first time (R1) has had issues. They (facility) separated (R1) and (R3) a while back because (R1) was
yelling at (R3). I am just glad no one got hurt.
On 10/10/24 at 1:25 PM V9 Community Relations Coordinator (CRC)/ Certified Nurse Aide (CNA) stated
staff were serving the residents their supper on 9/24/24. V9 stated, I heard yelling from the dining room, so I
turned to see what was going on. I saw (V10) Certified Nurse Aide (CNA) walking over to (R1, R2) table.
(R2) was standing in front of (R1) as (R1) was still sitting down. (R1, R2) were yelling profanities at each
other. (R4) was sitting at the table with them. (R4) just had his head down. (R4) did not yell or hit anyone or
anything like that. (R4) was literally just sitting there in between (R1, R2) with his head down. I heard (R2)
say 'Do you want some more?' to (R1) after (R2) hit (R1). (R2) sat back down as (V10) CNA was escorting
(R1) out of the dining room. (R1, R2) were both continuing to yell at each other as (V10) was walking (R1)
out of the dining room. (R2) got back up out of his chair and began walking towards (R1) again but I had
intervened and assisted (R2) back to his chair.
On 10/10/24 at 10:00 AM V1 Administrator stated R1, R2 and R3 were sitting in the dining room. V1 stated
R1 and R2 were sitting at the same table and R3 was sitting two tables away from R1 and R2. V1
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145370
If continuation sheet
Page 3 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145370
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sullivan Healthcare & Senior Living
11 Hawthorne Lane
Sullivan, IL 61951
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
stated R1 yelled 'you (R3) are a f****** r***** (expletives)!'. V1 stated then R2 told R1 he could not call
people those names. V1 stated R1 then yelled at R2 calling him (R2) a f****** r***** (expletives). V1 stated
that made R2 mad so R2 swung at R1. V1 stated by that time, staff had intervened between R1 and R2. V1
stated as staff were attempting to remove R1 from the dining room, R2 got back up from his dining room
table a second time and tried to swing at R1 again. V1 stated R1 and R2 were yelling at each other and R2
swung at R1 three times total. V1 stated R1 reported that R2 did hit him. V1 stated this incident happened
in front of other alert and oriented people.
Event ID:
Facility ID:
145370
If continuation sheet
Page 4 of 4
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
FAQ · About this visit
Common questions about this visit
What happened during the October 10, 2024 survey of SULLIVAN HEALTHCARE & SENIOR LIVING?
This was a inspection survey of SULLIVAN HEALTHCARE & SENIOR LIVING on October 10, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SULLIVAN HEALTHCARE & SENIOR LIVING on October 10, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect b..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.